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Diseases of Lids

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									      Diseases of Lids

 Power point copy of Lecture taken by
       Prof Sanjay Shrivastava
   For Junior Final Year students of
Gandhi Medical College, Bhopal (M.P.)
Anatomy of Lid
Hordeolum Externum
   Hordeolum Externum (Stye)
Definition: Localized suppurative
 inflammation of gland of zeis at lid margin
 at ciliary follicle.
• Usually caused by staphylococcus aureus
• There is infection of hair follicle of eyelash.
• It may complicate Acne Vulgeris in young
• Purulent infection of follicle and its gland
  with cellulitis of surrounding connective
            Clinical Picture
• Stye are frequently recurrent, appearing in
• Recurrent lesion is particularly seen in
  cases of debility, focal infections and
• Severe pain which is sharp throbbing ,
  feeling of fullness or heaviness and feeling
  of heat
• Tenderness (increase in pain on touching
  swelling/ affected area)
• Pain subsides on escape of pus
• Starts usually as
  edema of the lids with
• Yellow pus point
  appears on the lid
  margin around the
  root of a lash at the
  most prominent part
  of the swelling
               Signs … contd
• Skin gives way and pus
  drains with sloughing
• Swelling subsides and
  cicatrix form
• Spread of infection to
  neighbouring lashes
  opposite lid margin and
  conjunctival sac
• Subsidence of
  inflammation may leave
  area of induration
Hordeolum Externum
• Cellulitis (particularly in cases of lesion at
  inner canthus)
• Orbital thrombophebitis (leading to
  cavernous sinus thrombosis and its
I.   Systemic
     a. Antibiotic
     b. Anti-inflammatory analgesic
     c. Supportive
     d Treatment of associated systemic
     predisposing cause
II. Local
   a. Hot fomentation
   b. Local broad spectrum antibiotic drop
   and ointment
   c. Evacuation of pus when pus points,
   sometimes epilation may be required
   before evacuation of pus (lid margin/
   lesion should never be squeezed)
Hordeolum Internum
        Hordeolum Internum
• Hordeolum Internum is a suppurative
  inflammation of meibomian gland.
• It may be due to secondary infection of
  meibomian gland or it may start to begin
  with as suppurative infection of meibomian
• This condition is more symptomatic than
  stye, the gland is larger and is located in
  fibrous tarsal plate
• Pain, which may be severe throbbing
• Swelling , which is away from lid margin
• Pus pointing either at the lid margin or on
  the palpabral conjunctiva
• Swelling of affected lid, due to associated
• Swelling is more marked about 4-5 mm
  from lid margin
• Tenderness
• Palpabral conjunctiva over the swelling is
  congested a pus point may be visible
• Pus point may be visible at the lid margin
Hordeolum Internum
    Treatment of Hordeolum Internum
•     Medical treatment is similar to treatment of
      Hordeoulm externum i.e.
      a. Antibiotic
      b. Anti-inflammatory analgesic
      a. Hot fomentation
      b. Local broad spectrum antibiotic drop and
 Possible outcome of Treatment
• It may resolve with evacuation of pus at the lid
• It may burst on palpabral conjunctiva, leading to
  infective bacterial conjunctivitis and persistence
  of growth on palpabral conjunctiva, resembling
  papilloma. It due to fungating mass of
  granulation tissue sprouting through opening. It
  causes irritation and conjunctival discharge
• It turns into chronic granuloma i.e. Chalazion
• Chalazion is also called tarsal cyst or meibomian cyst
• Chalazion is chronic inflammatory inflammatory
  granuloma of meibomian gland
• Seen in adults more often as multiple lesions occurring
  in crops
• The glandular tissue is replaced by granulation tissue
  consisting of gaint cells, polymorphonuclear cell, plasma
  cells and histiocytes, indicating reaction to chronic
  irritation. The opening of meibomian gland is occluded
  leading to retention which acts as cause of chronic
Hard painless swelling little away from lid
Swelling increases gradually in size without
Small chalazia are better felt than seen
Multiple lesions and large chalazion may be
 associated with inability to open eye fully
• Signs:
  Painless swelling 4-5 mm away from lid margin. Swelling
  is hard
  On conjunctival side it appears red or purple. In long
  standing lesions it appears grey. In old lesion granulation
  tissue turns into jelly-like mass.
  Chalazion may become smaller over the period of time ,
  but complete resolution may occur only rarely
  Sometimes the granulation tissue is formed in the duct
  and project at the intermarginal strip as a reddish grey
Adenoma of Meibomian Gland
      Treatment of Chalazion
• Intralesional injection of Triamcinolone
  Acetonide may help in resolution of
• Incision & curette of chalazion is indicated
  in cases when it causes disfigurement and
  mechanical ptosis due to its weight
          Steps of operation
• Explain about condition and operation
• Informed consent
• Topical anaesthesia and sub-muscular
  infiltration of 2% Lignocaine
• Application of chalazion clamp around the
  nodule (this will provide field for bloodless
  operation, hard base and protect deeper
  soft structures). Lid is everted
• Infiltration of lignocaine around swelling
• Vertical incision on most prominent point/
  point of greatest discolouration with sharp
  scalpel blade
• Semi-fluid/ cheesy contents are taken out
  with small chalazion scoop (Curette)
• Pseudocapsule/ cavity is excised or the
  cavity is cauterized with pure carbolic acid
  or 10-20% trichloracetic acid
• Clamp is removed, and pressure is applied
  on lid to stop bleeding or pressure
  bandage is applied for few hours
• Swelling remains for few days after
  surgery as the cavity is filled by blood
• Post-operatively analgesic may be needed
  systemically. Local antibiotic drop and
  ointment for one to two weeks
• Very hard chalazion near canthi may be
  adenoma of gland and requires excision
• Recurrent lesion particularly in elderly
  patients should be investigated for
  meibomian gland carcinoma (by biopsy)

• Blepharitis is chronic inflammation of lid
  margin occurring as true inflammation or
  as simple hyperaemia.
1. Anterior
    a. Squamous
    b. Ulcerative
2. Posterior
    a. Meibomian seborrhoea
    b. Meibomianitis
1. Following chronic Conjunctivitis
   especially due to staphylococci
2. Parasitic infection, Blepharitis acarica
   due to Demodex Folliculorum and
   Phthiriasis Palpabrarum due to crab
       Seborrhoeic or Squamous
• Is a form of anterior blebharitis characterized by
  deposition of white scales among the eye
  lashes. Eye lashes fall and replaced by
  undistorted eyelashes.
• On removal of scales, lid margins appear
  hyperaemic. Ulcers are absent.
• Condition is metabolic associated with dandruff
  of the scalp
• Usually associated with seborrhoeic dermatitis
  involving scalp, nasolabial folds and
  retroauricular areas
Squamous Blepharitis
• Burning, deposits / crusting along lid
  margins, grittiness , redness of lid
  margins, photophobia
• Symptoms are worse in the morning
      Seborrhoeic or Squamous
• Skin condition also requires treatment.
• Cleaning of lid margin with baby shampoo.
  In case of bacteria infection, local
  antibiotic drops and ointment. Associated
  tear film dysfunction, if present is treated
  with artificial tear drops
    Staphylococcal or Ulcerative
• Ulcerative blepharitis is infective condition
  commonly due to staphylococcal infection
• Lid margins are covered with infective
  material (yellow crusts or dry brittle scales)
  matting eyelashes. On removal of
  discharge small ulcers which bleed are
  found along lid margins around bases of
  the eyelashes
• Redness of lid margins, burning, itching,
  watering and photophobia
• Signs:
  – Small ulcers at lid margins on removal of
    discharge, this features differentiate it from
Ulcerative Blepharitis
• Discharge/ crust is removed from lid
  margins with 1:4 dilution baby shampoo or
  luke warm 3% soda bicarbonate lotion.
  The loose discharge is then cleaned
• Diseased eyelashes are epilated
• Appropriate antibiotic drops are used
• After control of infection, daily cleaning of
  lid margins with blend lotion

• Improvement of local hygiene (rubbing of
  eyes and touching of eyes with dirty hand
  should be discouraged)
 Sequelae of Ulcerative Blepharitis
• Chronic course and associated chronic
• Madarosis (Scanty eyelashes) due to
  falling of eyelashes
• Trichiasis (misdirected eyelashes) due to
  contraction of scar tissue
• Cicatrization of lid margins causing
  thickening and hypertrophy of tissue and
  drooping of lids (Tylosis)
 Sequelae of Ulcerative Blepharitis
• Cicatrization of lid margin may drag
  conjunctiva on posterior border of
  intermarginal strip disturbing angle of
  posterior edge leading to epiphora ,
  eversion of puncta
• Epiphora leads to eczematous condition of
  skin, scarring of skin leads to ectropion .
  This further aggravate epiphora
         Posterior Blepharitis
• Posterior blepharitis i.e. inflammation of
  meibomian duct opening at intermarginal strip
  and posterior border may cause tear film
  instability and inferior punctate keratitis
• It occurs in two clinical forms
  a. Meibomian seborrhoea – characteristic
  appearance of oil droplet at the opening of
  meibomian duct opening at intermarginal strip.
  Tear film is oily and foamy. Frothy discharge
  accumulate on the lid margin. Foam like
  discharge can be expressed from these lesions
      Posterior Blepharitis
b. Meibomianitis – There is inflammation
and obstruction of meibomian glands.
Characterized by diffuse thickening of
posterior border of lid margin which
becomes rounded. On lid massage
toothpaste like thick material can be
expressed out. Due to duct blockade cyst
formation may be present
• Chalazion
• Tear film instability
• Papillary conjunctivitis and inferior corneal
• Warm compresses
• Systemic - Doxycycline 100 mgm twice x 1
  week then once daily for 6 -12 weeks or
  Tetracycline 250 mgm 4 times x 1 week
  then twice for 6 -12 weeks
• Associated tear film abnormality is treated
  with artificial tear drops
         Lower lid retractors
a. Inferior lid retractors:
   1. The inferior tarsal aponeurosis –
   capsulo-palpabral expansion of the
   inferior rectus muscle and is analogous
   to the levator aponeurosis
   2. Inferior tarsal muscle is analogous to
   muller muscle
Entropion is in-rolling of eye lid margin.
Normal position of sharp posterior border of
inter-marginal strip is essential for interigrity of
the tear film and for maintenance of healthy
ocular surface

Entropion is caused by disparity of length and
tone of anterior skin muscle layer and posterior
tarso-conjunctival layer of the eyelid
      Symptoms of Entropion
• Foreign body sensation
• Watering
• Redness
• Pain
• Photophobia
These symptoms are due to rubbing of
  ocular surface by misdirected eyelashes
1.   Involutional
2.   Cicatricial
3.   Spastic
4.   Congenital
     Involutional Entropion
This condition is due to old age, due to
instability of lid structures
There occurs:
a. Weakness of the posterior retractor of
the lid
b. Laxity of medial and lateral canthal
c. Atrophy of orbital pad of fat leading to
        Involutional Entropion
• There occurs of over-ridding of preseptal
  orbicularis muscle over pretarsal
  orbicularis, that leads to forward rotation of
  tarsal plate
• Seen in lower lids
Involutional Entropion
Involutional Entropion
       Treatment of Involutional
Principles of surgery
1. Reattachment of the retractor to tarsal
2. Shortening of horizontal width of lid
3. To induce scarring between the pre-
   tarsal and pre-septal parts of orbicularis
        Surgical Procedures
1. Catgut suture application through
2. Modified Bick operation: Horrizontal
   shortening of lower lid with fixation to
   lateral canthal ligament and periosteum
3. Tucking of inferior lid retractors
        Cicatricial Entropion
• Caused by contraction of scar tissue of the
  palpabral conjunctiva
• In this case there is relative shortening of
  inner layer i.e. tarso-conjunctiva
• Caused by scarring of palpabral
  conjunctiva by trachoma, trauma, chemical
  injuries (burns), pemphigus and Stevens-
  Johnson syndrome
Principles of surgery
1. Tarsal rotation (forwards)
2. Lengthening of posterior lid lamina so
   that eyelashes turn forwards
a. Wedge resection (Tarsal paring)
b. Tarsal fracture
            Spastic Entropion
• This condition is due to spasm of orbicularis in
  presence of degeneration of the palpabral
  connective tissue separating orbicularis fibres.
  The spasm is induced by local irritation in
  inflammatory and traumatic conditions.
• Factors that prevent in-rolling of lid margin:
  a. intact inferior lid aponeurosis which maintains
  orbicularis in position that it presses against
  lower tarsus
  b. contraction of palpabral head of inferior rectus
• Degeneration of aponeurosis, the strong
  contraction of orbicularis is associated with
  turning inwards of lid margin
• Senile degeneration of tarsal muscle of
  Muller fails to anchor the lower border of
  tarsal plate to bony orbit
• Orbicularis rides up on tarsal plate towards
  lid margin
• Horizontal lid laxity
            Clinical picture
• Condition is found in elderly patients
• Tight bandaging may cause spastic
• Narrowness of palpabral aperture
• Seen in lower lids
Treatment of Spastic Entropion
• Removal of cause i.e removal of cause of
  irritation, tight bandaging
• Treatment of surface disorder by artificial
  tears and control of conjunctival infection
  and lid inflammation with antibiotic
• Fixing of lower lid after everting it with
  adhesive tape
• Injection of Botulinum toxin into pre-tarsal
  orbicularis to weaken it
          Surgical treatment
• Producing a ridge of fibrous tissue in the
  orbicularis to prevent its fibres from sliding
  in vertical direction
       Congenital Entropion
• This condition is due to dysgenesis of
  lower lid retractor or due to abnormal
  development of tarsal plate.
• This condition must be differentiated from
  epiblepharon (due to anomalous fold of
  skin pushing lashes upwards onto the
• Treatment of abnormality
• Ectropion is out-rolling of lid margin
• Symptoms are:
  Watering (due to eversion of punta)
  Foreign body sensation
  Photophobia (Due to involvement of cornea)
  Symptoms are due to eversion of punta, and
  exposure of ocular surface, chronic conjunctivitis
  caused by exposure and drying of surface
I. Acquired
• Involutional or senile
• Cicatricial
• Paralytic
• Mechanical
II. Congenital
           Functions of lids
1. Protection of eye
2. Act as lacrimal pump

Effect of age
   Slowly there is relaxation of lid structures
   (canthal ligament and orbiularis)
       Involutional Ectropion
1. Early stage: in mild cases on looking up
   the puncta is not apposed to bulbar
2. Progresses to moderate stage puncta
   are not apposed to bulbar conjunctiva
   even in primary gaze and entire lid
   margin fall away from the globe
        Involutional Ectropion
3. In severe case lower lids are rolled out and
  palpabral conjunctiva (including tarso-
  conjunctiva and fornix are exposed)
Chronic exposure of lower puncta on everted lid
  leads to phimosis of puncta
Tears are no longer drained into nose and
  overflow onto the cheek
In long standing cases keratinization of the lid
  margin and palpabral conjunctiva takes place
• Signs as described with three stages earlier
• In ling standing cases the exposed conjunctiva
  becomes dry, thickened, red , un-sightly. Cornea
  may suffer from imperfect closure of the lids
• Diagnosis is confirmed if lower lids does not
  snap back into position after pulling it 6-7 mm
  away from globe. If canthal displacement is
  more than 2 mm on pulling lower lid laterally or
  medially , canthal laxity is diagnosed
• There is horizontal lengthening of the lids
• Surgical treatment:
  in mild to moderate cases, excision of 7 – 8 mm
  long x 4 mm high conjunctival exicion 5 mm
  below lid margin (puncta), this puts back puncta
  in its normal position
  In more marked cases 5 mm full thickness
  shortening/ resection of lid 5 mm from puncta, by
  giving inverted house shaped incision (modified
  Kuhnt Szymanowski operation at lateral canthus
  or modified Lazy T operation at medial canthus)
         Cicatricial Ectropion
• Is out-rolling of lid marging due to
  contraction of scar tissue on skin side.
  Commonly results from lid trauma, burns,
  chemical injuries and chronic
  inflammations of lid skin. Due to
  contraction of scar the lid skin shortens
  pulling the eyelid away from the eyeball
Cicatricial Ectropion
Ectropion Pre and Post-operative
• Principle of surgery:
  release and relaxation of the scar tissue
  and restoration (elongation) of skin by
  Localized small scar may be treated by V-
  Y operation
  Large scar requires excision of scar tissue
  and application of matching (whole or spilt)
  skin graft
            Paralytic Ectropion
• This condition is due to paralysis of the facial nerve due
  to Bell palsy, surgery on parotid gland and trauma
• Characterized by presence of other signs of facial palsy
• Initially treated by conservative treatment by taping of
  lids, lubricating eye drops, till there is recovery
• Lateral tarsorrhaphy, by suturing freshened upper and
  lower lids at outer canthus
• Lagophthalmos due to weakness of superior orbicularis
  may be treated by taping

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